Some Cleveland Clinic patients are so mad about a fee that recently began showing up on their outpatient bills that they're complaining to the hospital, their insurance companies, even members of Congress.

In the current economy, they say, the charge is one more expense they can't afford.

So do hundreds of other hospitals across the country. And they have for years.

Facility fees, as their name implies, help hospitals pay for overhead costs including building maintenance, equipment, supplies, staff salaries, streamlined transfer of records and subsidized care for the poor. The fees vary tremendously, depending on whether a patient gets an injection or has surgery.

Hospitals say they need them to survive.

"If the Cleveland Clinic elected not to have facility fees at all, we wouldn't be able to stay in business," says Steven Glass, the Clinic's chief financial officer, "because we wouldn't be able to recover our costs."

Where to call for answers

At the Cleveland Clinic, call Patient Financial Services at 216-445-6249 or 1-866-621-6385.

The reason the fees are an issue now is that as of March 1, the Clinic began adding them to bills for outpatient treatment at nine of its 15 family health centers -- in Beachwood, Brunswick, Independence, Lakewood, Lorain, Solon, Strongsville, Westlake and Willoughby Hills.

"These are not new charges, we've been billing them in various locations for years," Clinic spokeswoman Heather Phillips said when asked why the Clinic began charging them March 1 and why only at some facilities.

"Our goal is to have all facilities which meet the legal requirements to serve as provider-based facilities and bill accordingly," she said.

Health-care experts say patients can avoid the fee by choosing doctors in private practice instead of those in hospital-owned practices. Some patients say that's exactly what they're going to do.

Frost and other patients might not have complained about the fee, if their health insurance covered all of it. But in many cases it doesn't.

Insurance rules vary, but what often happens is that patients with private insurance end up paying all of the facility fee until they reach their deductible. At the nine Clinic facilities, for example, a person with a $25 co-pay now pays $80 for an office visit because of the $55 facility fee.

Another reason many Clinic patients are angry is because they say they never received an explanation of the fee even though Clinic officials say they handed out and mailed more than 200,000 notices.

Other patients say they did receive a letter, but couldn't figure out what it meant. The letter didn't explain the facility fee. Instead, it said that "services will now be grouped into two categories on your billing statement."

The fees are becoming more common as hospitals take over more and more medical practices which must meet the hospitals' higher standards.

The Clinic facilities, Glass says, are accredited by The Joint Commission, a nonprofit organization that certifies that hospitals and other health-care facilities have met patient safety, quality-of-care and other standards.

The fee is rooted in regulations that govern Medicare -- the federal government's health-care plan for the elderly. It's designed to reimburse hospitals for their overhead costs. Medicare has paid it for years. The reason the Medicare payment rules matter to the rest of us is because Medicare won't reimburse a hospital for a fee charged to its patients unless the hospital charges that fee to non-Medicare patients, too.

"One of the key requirements for getting reimbursement from Medicare is that you must treat every patient the same," the Clinic's Glass explains. "You must bill uniformly."

So if hospitals don't bill everyone for facility fees, they can't collect them from Medicare patients. At the Clinic, 40 percent of patients are covered by Medicare, according to a spokeswoman.

But others say hospitals are using the facility fees as another way to generate more money.

One billing consultant's Web site says facility fees typically bring a hospital an additional $30,000 a year -- per doctor.

"Hospital margins are down," he said. "Their investment income is down and some of their patient revenue is down because there are fewer insured people and fewer paying customers."

He also says that hospitals are not being forced by Medicare to charge facility fees.

"What it seems like the hospitals are doing here," he says, "are unloading some of their overhead costs on the hospital-owned ambulatory centers."

Facility fees have caused enough anger in other parts of the country that lawyers and lawmakers have stepped in.

In Wisconsin, state representative Chuck Benedict, a retired doctor, has proposed a law that would require hospitals to notify patients of the fees and provide them with good-faith estimates in advance.

In Seattle, attorney John Phillips filed two class action suits against hospitals there for not telling patients about the fees up front so they could try to avoid them. In the end, the hospitals agreed to two things: to post signs stating the facility charged the fee and to provide patients with good-faith estimates of what they would have to pay.

Glass says the Clinic won't post such signs.

Instead, he said, patients should look for signs that identify buildings as a hospital facility. If they're being treated in a hospital facility, he says, they should know they'll be charged a facility fee.

If patients aren't happy with that, they can do more than try to find a doctor in private practice, says Suzanne Lestina, senior technical manager for the Healthcare Financial Management Association, an organization of health-care financial professionals which, among other things, spearheads the Patient Friendly Billing project.

Consumers can confront their insurance providers and ask them why they aren't paying the fee, she says.

Cleveland Clinic patients have been doing just that, says George Stadtlander of Medical Mutual of Ohio. The insurance company has had dozens of calls about the Clinic's new fee.

"Our customer service team is collecting information from our customers and they're adjusting claims to reduce or eliminate the impact of the change in billing," says Stadtlander, chief underwriter and vice president for individual and small group markets.

That doesn't mean that patients won't end up paying at least a portion of them, Stadtlander said.

His company he says is working with the Clinic to resolve a complicated issue. "We're not pointing fingers at each other, we're shaking hands and working together and, from the customer's point of view, adjusting these bills," he said.

That collaboration should've happened long before the fees went into effect, says Steve Trattner, president and chief marketing officer for Cinergy Health, a national health insurance benefits company based in Florida.

"The approach the hospital should've taken is not to throw it in the lap of patients, but to . . . work with the insurance company before they changed the billing practice," he said.

"This is exactly the kind of situation where there's confusion, there's a lack of clarity about the rules of the game and the consumer gets stuck holding the bag," says Susan Sherry, deputy director of Community Catalyst, a national, nonprofit organization working for quality, affordable health care for everyone. "This is feeding the consumers' demand for health-care reform."